HHS' Office of the Inspector General is advising CMS to take more caution in paying for negative pressure wound therapy pumps by requiring suppliers to submit patient medical records with all Medicare claims.

"CMS should consider strengthening the coverage criteria for the pump and increasing prepayment reviews of these claims," OIG concludes in a ¹ report, released July 9, analyzing 378 pump claims made in 2004.

In a response to OIG included in the report, CMS says it needs more information before strengthening the coverage criteria for the pumps, although it is willing to consider any specific additional criteria OIG has in mind.

CMS says the report does not provide sufficient information to support increasing the frequency of prepayment reviews of pump claims. "Given that a NPWT pump is often prescribed in urgent situations, such a time delay could be problematic."

OIG concludes that almost a quarter of all 2004 claims for these pumps did not meet CMS coverage criteria, directly costing Medicare about $21 million in improper payments plus another $6 million in improper payments for supplies associated with those claims.

OIG says 15% of the claims did not have sufficient documentation to show that the claim met Medicare criteria; 6% of claims were undocumented; and 3% were not medically necessary. On 44% of the claims that included both a medical record and a statement from a clinician, the information in the statement was not fully supported by the medical record.

OIG says it undertook the review because Medicare payments for these pumps increased 444% from 2001 to 2005.

CMS says it will prioritize medical reviews of claims for negative pressure pumps, require that medical reviews of pump claims be based on the "entire medical record," and direct its contractors to develop an education article based on the OIG report.

Manufacturers of negative pressure wound therapy products include Kinetic Concepts and BlueSky Medical, recently purchased by Smith & Nephew.

- Reed Miller (re.miller@elsevier.com)

HHS Inspector General Warns CMS It Is Overpaying For Wound Pumps

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